Incisionless Endoluminal Gastric Tissue Approximation for the Treatment Of Obesity

ABSTRACT

An incisionless fully endoscopic method of reducing the capacity of the stomach is provided to surgically treat obesity. The method is directed to endoluminal tissue approximation of a portion of the stomach, including at least a portion of the greater curvature thereof. The method includes a pattern of stitching in which a portion of the stomach is closed off. One stitching pattern causes the lateral portion of the stomach to be drawn to reduce the usable volume of the stomach while maintaining a pathway from the esophagus to the pylorus. As the stitching pattern advances, the fundus is automatically drawn downward so that it may be endoscopically approached for stitching in a facilitated manner. According to another aspect of the invention, another stitching pattern extends from the antrum to the fundus between the anterior and posterior portions of the stomach.

CROSS-REFERENCE TO RELATED APPLICATION

This application claims benefit to U.S. Provisional Ser. No. 61/900,049,filed Nov. 5, 2013, which is hereby incorporated by reference herein inits entirety.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to surgical procedures. More particularly,the invention relates to a method of effecting stomach reduction totreat obesity. Specifically, the method is directed to an endoscopicincisionless procedure to reduce the internal volume of the stomachwithout relocating the small intestines.

2. State of the Art

The condition of obesity means an individual has too much body fat andalso that an individual's weight is higher than what is considered to behealthy for their height. Biology plays a big role in why some peoplebecome obese, but not getting enough exercise, eating more food than thebody can use, and drinking too much alcohol also contributes to peoplebecoming obese. Obesity is a major health threat because excess weightputs more stress on every part of the body and puts people at risk ofseveral health problems, such as diabetes, heart disease, and stroke.

For some people, lifestyle changes like maintaining a healthy diet andexercising regularly can help them drop body fat and stop being obese.For others though, it can be extremely difficult to lose body fat andconsistently maintain weight loss. Medications for losing weight areavailable on the market, but some can have serious side effects and maynot actually be effective. For obese individuals who can not lower theiramount of body fat through lifestyle changes or medications, varioussurgical options have become available.

Gastric bypass surgery was the first commonly practiced procedureperformed to make the stomach smaller. The procedure involves staplingportions of the stomach wall together and then relocating a small partof the small intestine to the newly formed stomach pouch. By reducingthe size of the stomach, the stomach holds less food, the individualobtains a sensation of fullness quicker, fewer calories are eaten, fewercalories are absorbed, and weight loss results. However, there aredownsides to the procedure. The procedure is an open surgical procedurewhich has its own risks, including the potential for complications andinfection, and can have an extensive post-surgical recovery period. Theprocedure is also relatively complicated requiring a reconfiguration ofthe small intestines. Also, over time the staples can release allowingthe stomach to re-enlarge, rendering the procedure less effective.

Another procedure is the ‘gastric banding’ procedure, primarily with theLAP-BAND® system, in which an inflatable band is inserted through theabdomen and about the stomach in either a laparoscopic procedure. Theband is wrapped around the upper part of the stomach to form a stoma, orring. Attached to the ring is a thin tube leading to an access port thatis implanted under the skin. A balloon attached to the band contacts thestomach and can be inflated (or deflated) with saline via the accessport using a needle. Adding saline tightens the stoma about the stomachto effect an earlier sensation of satiety. If the band is too tight,saline can be withdrawn. An advantage of the gastric banding is that itcan be performed in a minimally invasive manner with small laparoscopicincisions into the abdomen with consequent reduced recovery time, andthat no reconfiguration of the small intestines is required.Nevertheless, the procedure still requires incisions, infection canresult, and can the recovery can be uncomfortable. In addition, thepatient is left with a permanent port just under their skin which can beundesirable to some.

These types of procedures, when all goes well, can be effective, but asstated come with the risks associated with open or laparoscopic surgery,and for that reason they are only prescribed in cases of extremeobesity.

A more recent procedure called Primary Endoluminal Obesity Surgery(POSE) is carried out endoscopically via the gastroesophagheal tractinto the stomach, completely without incisions. The procedure includesthe creation of a series of plications solely in the gastric fundus thatare maintained with respective clips. With the creation of eachplication, two locations of stomach tissue are gathered, drawn together,and secured, with the result that the stomach capacity is reduced. As aconsequence, the patient has somewhat diminished hunger cravings. ThePOSE procedure theoretically offers an advantages over the othersurgeries requiring an incision: less pain, decreased risk of infection,no external scarring, faster recovery, shorter hospital stay to name afew. However, the amount of stomach capacity reduction that can bepractically be achieved with POSE is controverted. Acting solely on thefundus and in the manner practiced, it is thought to be significantlyless that the seventy percent reduction in capacity claimed by thedevelopers of the procedure; it may be more realistic to anticipate athirty percent reduction in stomach capacity with the POSE procedure.Moreover, working endoscopically to create clipped plications in thefundus is difficult, as the endoscope and tools working through thechannels of the endoscope must be operated in a retroflexed manner,which makes access to the fundus, maneuvering of the instruments, andreducing the fundus challenging.

SUMMARY OF THE INVENTION

An incisionless fully endoscopic method of reducing the capacity of thestomach is provided to surgically treat obesity. Broadly, the method isdirected to endoluminal tissue approximation of a portion of thestomach, including at least a portion of the greater curvature thereof.In one aspect of the invention, the method is directed to a pattern ofendoscopic stitching in which a significant portion of the stomach isclosed off. According to one aspect of the invention, the anterior andposterior walls of the stomach are marked along the greater curve of thestomach to create guidelines for sutures. The guideline may be made witha coagulator, dye or other marking device or substance. The stitchingpattern subsequently proceeds along the guidelines.

According to yet another aspect of the invention, one stitching patterncauses the lateral portion of the stomach; i.e., extending along thegreater curve of the stomach to be drawn in or collapsed inward tothereby remove such portion of the greater curve from the usable volumeof the stomach while maintaining a usable pathway from the esophagus tothe pylorus. The pattern is initiated below the fundus, and as thepattern advances, the fundus is automatically drawn downward so that itmay be endoscopically approached for stitching without necessitating anyor any significant retroflex of the endoscope and stitching instrumentsused therewith. In this manner, the method provides a procedure in whichaccess to the anatomy being sutured is facilitated relative to prior artincisionless stomach reduction procedures. According to another aspectof the invention, another stitching pattern extends from the antrum(lower portion) to the fundus (upper portion) between the anterior andposterior portions of the stomach.

More particularly, a preferred method includes, for each of a pluralityof vertically displaced locations along the greater curve of thestomach, suturing three points about the stomach together and cinchingthe three points toward each other. The three points are located at ananterior side, a posterior side, and a lateral side. The three pointscan be attached in a point-to-point arrangement; i.e.,anterior-to-posterior, posterior-to-lateral, and lateral-to-anterior,and when each of the point-to-point locations is cinched the greatercurve of the stomach collapses inward to eliminate the volume of suchportion of the stomach at the cinched locations.

More preferably, the three points are sutured in a continuous process inwhich each of the anterior, posterior and lateral points are coupledtogether with a single suture and then cinched. A helical suturingpattern may be used in which an arrangement of vertically displaced setsof anterior, posterior and lateral points are coupled together with asingle suture and cinched to draw the greater curve of the stomachinward upon itself and reduce the stomach volume thereat. It isanticipated that five to seven such helical suturing patterns, each witha separate suture, are used to fully draw in and collapse the greatercurve of the stomach.

In accord with a preferred aspect of the invention, the helical suturingpattern starts at or adjacent the antrum; subsequently, the helicalsuturing pattern continues to the body of the stomach. Alternatively,the stomach can be helically sutured in order: antrum, then fundus, andfinally body. Once the antrum and/or body are sutured and cinched, thecinching causes the fundus to be automatically drawn downward toeffectively shorten the length of the fundus. As the shape of the fundusis altered, it can be approached for suturing without retroflexing theendoscope or other instruments. This greatly facilitates the procedure.

After the greater curve of the stomach has been drawn into a collapsedconfiguration from the antrum to the fundus to effectively close off asignificant volume of the stomach, the anatomical revision is secured byrunning a vertical pattern of suture stitches between the anterior andposterior sides of the stomach at locations medial of the previouslydrawn in and secured tissue; i.e., along the lesser curve, to furtherseal off the cinched portion of the stomach and ensure a patent pathwaybetween the esophagus and the pylorus.

The resulting stomach reduction procedure provides a seventy toseventy-five percent reduction in available stomach volume, greater thanany other incisionless procedure. Also, because it is incisionless, itis safer to patients and offers an easier recovery. Moreover, as anincisionless procedure, it is easier for the surgeon to effectivelyperform than other incisionless procedures, providing more direct accessto the fundus for reduction.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a schematic illustration of the stomach.

FIG. 1B is a schematic illustration from inside the stomach, viewed fromthe fundus toward the pylorus.

FIG. 2A is a schematic illustration of the stomach, shown with markinginstrument inserted therein to provide guidemarks parallel to thegreater curvature.

FIG. 2B is a schematic illustration from inside the stomach, showinganterior and posterior guidemarks parallel to the greater curvature.

FIG. 3 is a partial section view of stomach, illustrating placement of afirst suture of a first suture stitching pattern according to the methodof the invention.

FIG. 4 is a view similar to FIG. 2A, showing the first suture of thefirst suture stitching pattern as FIG. 3.

FIG. 5 is a view similar to FIG. 4, showing the first suture cinched.

FIG. 6 is a schematic side view of stomach illustrating the cinchedantrum as a result of the first cinched suture and the correspondingreconfiguration of the greater curvature of the stomach.

FIG. 7 is a view similar to FIG. 5, illustrating a second suture of afirst suture stitching pattern, and the first suture cinched.

FIG. 8 is a view similar to FIG. 7, illustrating a third suture of afirst suture stitching pattern, and the first and second suturescinched.

FIG. 9 is a schematic side view of stomach illustrating the cinchedantrum, body, and fundus, and the corresponding reconfiguration of thegreater curvature of the stomach.

FIG. 10 is a schematic illustration from within the stomach, after thefirst suture pattern has been completed, and showing placement of thesecond suture pattern in the anterior-posterior direction.

FIG. 11 is a schematic side view of the stomach illustrating the cinchedsutures of both of the first and second suture patterns.

FIG. 12 is a perspective view of an endoscopic suturing system.

FIG. 13 is a broken partial section view of a distal end of theendoscopic suturing system extending through the distal end of anovertube.

FIGS. 14 through 17 illustrate operation of the endoscopic suturingsystem to endoluminally place stitches of suture through stomach tissue.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

Referring now to FIG. 1A, an illustration of the stomach 10 withstandard reference locations are shown. The gastroesophagheal junction14 at the upper end of the stomach is joined to the lower end of theesophagus 12, and the pylorus 16 defined at the lower end of the stomachis joined to the duodendum 18 of the small intestines. The upper portionof the stomach is the fundus 20 and extends vertically above of thegastroesophagheal junction 14, the central portion is the body 22, andthe lower portion of the stomach is the antrum 24. The medial side ofthe stomach forms a concave curve referred to as the lesser curvature(or curve) 26, whereas the lateral side of the stomach forms a largerconvex curve referred to as the greater curvature (or curve) 28.

Turning now to FIG. 1B, an interior of the stomach is shown, viewed fromthe fundus (top) toward the pylorus (bottom). In addition, the anterior(A), posterior (P), lateral (L), and medial (M) sides of the stomach areidentified. The lateral side (L) extends with the greater curvature 28of the stomach, and the opposing medial side (M) extends with the lessercurvature 26 (see FIG. 1A).

In accord with a general description of the method of the invention,described in more detail below, instruments are provided and used toendoscopically reduce the volume of the stomach by first reducing thevolume of the body 22 and/or the antrum 24 of the stomach, and thenreducing the volume of the fundus 20 of the stomach. The term‘endoscopically’, as used herein, means through or with the aid of anendoscope in which the instruments acting to reduce the stomach volumeare inserted through a natural orifice, namely the gastroesophaghealpathway, preferably without incision to either the dermal or internaltissues of a patient in order to effect for passage of the requiredinstruments. Specifically, it is recognized that suturing does noteffect an incision in tissue. In addition, the term ‘vertically’ as usedherein is in reference to the upper and lower portions of thegastrointestinal tract in relation to the passage of nutrients, i.e.,with the upper end (fundus) located vertically above the lower end(pylorus) regardless of the orientation of the patient.

Generally, an endoscopic method of reducing the capacity of the stomachis provided to surgically treat obesity. The reduction of the stomach isperformed by endoscopically drawing together and approximatingpreferably three peripherally displaced locations of the stomach wall(at the anterior side (A), posterior side (P), and lateral side (L)),and cinching such locations into approximation. This process is carriedout at several vertically displaced portions of the stomach, preferablyincluding at each of the antrum 24, the body 22, and the fundus 20. Oncethe peripherally and vertically displaced locations of the stomach 10are endoscopically approximated to result in reducing the lateral sidevolume of the stomach (i.e., preferably covering substantially all ofthe antrum, the body, and the fundus of the stomach), preferably avertical row of stitches is endoscopically placed between the anteriorand posterior sides of the stomach to seal off the previously drawntogether portions of the stomach to result in a significantly re-sizedstomach volume and patent pathway between the gastroesophagheal junction14 and the pylorus 16.

More particularly, the method requires a pattern of endoscopic suturestitching in which a significant portion of the stomach is closed offwith stitches extending from the antrum 24 to the fundus 20 between theanterior (A) and posterior (P) sides of the stomach. The suture 54(shown in FIG. 3) is preferably any suitable suture material, e.g.,polymeric and/or metal, in the form of a filament, braid or cable. Aftergeneration of the suture pattern, the suture is cinched to cause thelateral side (L) of the stomach; i.e., that portion extending along thegreater curvature 28 of the stomach, to be drawn in or collapsed inward(toward the medial side (M)) to thereby remove such portion of thegreater curvature from the usable volume of the stomach whilemaintaining a pathway from the esophagus 12 to the pylorus 16.

Referring to FIGS. 2A and 2B, one preferred method includes marking theanterior and posterior sides A, P of the stomach 10 along the greatercurvature 28 of the stomach to create guidelines G_(A), G_(P) forsubsequent sutures. This is particularly helpful, as the guidelinesprovide a reference line or reference axes as the stomach tissue iscinched, as discussed below. The guidelines may be marked with acoagulator, dye or other marking device or substance. One preferredmarking device 100 is the argon plasma coagulator, which can be used tocreate a continuous guideline on the stomach lining. Another device thatcan be used is a needle knife and dye, which can generate dotted-line orcontinuous guidelines. The stitching pattern subsequently proceeds alongor relative to the guidelines G_(A), G_(P). The guidelines, whilepreferred, are not essential to the practice of the method.

After marking the guidelines, for each of a plurality of verticallydisplaced locations along the greater curve of the stomach, threedisplaced locations (suture ‘points’) along the stomach wall are suturedtogether and then cinched toward each other. The three points arelocated at an anterior side, a posterior side, and a lateral side. Thethree points can be attached in a point-to-point arrangement; i.e.,anterior-to-posterior, posterior-to-lateral, and lateral-to-anterior,and when each of the point-to-point locations is respectively cinched,the greater curve of the stomach collapses inward to eliminate thevolume of such portion of the stomach at the cinched locations. Theprocess would then be repeated at vertically displaced locations,preferably proceeding from the antrum toward the fundus.

Turning to FIG. 3, in one preferred procedure, the three points (A, P,L) are sutured in a continuous process in which each of the anterior,posterior and lateral points are coupled together with a single suture.More preferably, a helical suturing pattern is provided in which anarrangement of vertically displaced sets of anterior, posterior andlateral points, e.g., 50A, 50P, 50L and 52A, 52P, 52L are coupledtogether with a single suture 54. Each set preferably includes five toseven points of engagement about anterior, posterior, and lateral sidesof the stomach wall 56, engaged with the common suture 54. Referring toFIGS. 5 and 6, the suture 54 is then cinched to draw anterior,posterior, and laterals sides together into approximation, andconsequently the greater curve 28 of the stomach inward upon itself intoa collapsed configuration 58. This reduces the stomach volume in thearea engaged by the suture (FIG. 5). The suture 54 is retained to thestomach tissue 56 preferably with a retained needle 62 that operates asa tissue tag at one end of the suture 54, and an applied cinch 64 at theopposite end of the suture, discussed in more detail below.

As shown in FIGS. 3 through 5, the suturing and subsequent cinchingstarts below the fundus, e.g., at or adjacent the antrum. Referring toFIG. 6, as the anterior, posterior, and lateral sides of the stomach arecinched together with the suture starting from a relatively verticallylow location in the stomach (near the antrum), such cinching causes thefundus 20 to be automatically drawn downward to effectively shorten thelength of the fundus, comparing the reshaped fundus 20 to the originalconfiguration in dotted lines. As the shape of the fundus 20 is altered,the fundus can be subsequently approached for suturing withoutretroflexing the endoscope or other instruments required for thesuturing process. In this manner, the method facilitates access to theanatomy, and particularly the fundus, relative to prior art incisionlessstomach reduction procedures. It is anticipated that three to seven suchhelical suturing patterns, each with a separate suture, are used tofully draw in and collapse the greater curve of the stomach.

Thus, turning to FIG. 7, a second preferably helical pattern of suture66 is shown vertically above the lower collapsed stomach tissue 58,e.g., at or near the body 22 of the stomach. When suture 66 is cinched,the anterior, posterior, and lateral sides of the stomach wall are drawninto approximation at and adjacent the points of suture engagement. InFIG. 8, a third preferably helical pattern of suture 68 is shownvertically above both the lower cinched and collapsed stomach tissue andstomach tissue cinched and collapsed via the second suture pattern 66.In this example, the third pattern is shown inserted through the drawndown fundus 20. Additional suturing in a vertically displaced mannerfrom those shown, but preferably in the pattern described, is repeatedas necessary to collapse the greater curvature 28 from the antrum to thefundus to the configuration 70 shown in FIG. 9.

Turning to FIG. 10, after the greater curvature 28 is collapsed, inaccord with another preferred aspect of the invention, a running row ofa suture stitches is advanced from the antrum 24 to the fundus 20 alongthe collapsed portion of the stomach. It is preferred that a continuousvertical row of stitches be provided through the stomach alternating inthe anterior-posterior direction; e.g., by engaging the anterior side ofthe stomach wall with a suture 72, then passing the suture through theposterior side at a vertically higher location, then passing the sutureback through the anterior side at a vertically higher location thanengaged at the posterior, and so on. After the suture 72 is threadedthrough several locations in the alternating anterior-posteriorarrangement, the suture is cinched to draw the anterior and posteriorsides of the stomach wall together to define a relatively smooth passage74 between the lesser curvature and the now stitched tissue, as shown inFIG. 11. The passage 74 preferably excludes the approximation of thepreviously stitched anterior, posterior, and lateral sides. One or moresuture threads can be used to carry out the vertical row of sutures. Asan alternate embodiment, the anterior-posterior row of suture stitchesmay be comprised of several vertically displaced and substantiallycompletely discrete point-to-point anterior-posterior suture stitches toeffect the vertical row. Once the row is complete, several advantagesare provided. The row of stitches secures the prior reshaping of thestomach. The row of stitches further reduces the size of the stomach.The row of stitches provides a smoother and more well-defined passage 74from the upper to the lower ends of the stomach.

In order to endoscopically suture the stomach as described above, anendoscope is advanced through the esophagus and into the stomach. Theendoscope is provided with tools to effect endoluminal stitching ofsutures through the stomach wall. Co-owned US Pub. No. 2012/0157765,which is hereby incorporated by reference herein in its entirety,discloses a suitable and preferred endoscopic suturing system 80, shownat FIGS. 12 and 13, which is capable of the effecting the suturing ofthe stomach wall together in accord with the method described above. Theendoscopic suturing system 80 includes a steerable endoscope 82 and anendoscope-mounted needle passing system 84, which are togetherpreferably passed through the gastroesophagheal tract and into thestomach through an overtube 86. A display 88 is provided for viewing theimages from the endoscope. The system 80 operates in conjunction withinstruments passed through one or more of the working channels of theendoscope. More particularly, turning to FIG. 14, the system 80 allowsthe engagement of stomach tissue 56 (e.g., at the lateral side of thestomach) using a tissue grasper 90 extending through a first workingchannel 91 of the endoscope 82, a rotatable arm 92 mounted relative tothe end of the endoscope, the rotatable arm 92 releasably engaging aneedle 94 having a length of suture 96 fixed relative thereto. A controlhandle 98 (FIG. 12) is operable to rotate the arm 92 from an openconfiguration to an intermediate configuration (FIG. 15) to a closedconfiguration (FIG. 16) so as to pass the needle 94 and suture 96through the engaged tissue 56. A needle capture device (not shown)extends within a second working channel 97 of the endoscope 82 and, withthe arm 92 and needle 94 in the position shown in FIG. 16, is operatedto capture the needle 94 after it has been passed through the engagedtissue 56. The handle 98 is then operated to open the rotatable arm 92,resulting in release of the needle 94 from the rotatable arm 92, and theneedle 94 is retained at the capture device within the working channelof the endoscope. Referring to FIG. 17, the endoscope 82 can then beretracted relative to the tissue 56 to pull the suture 96 through thetissue, and once the distal end of the endoscope-mounted needle passingsystem 94 is free of the tissue, the rotatable arm 42 is rotated towardthe needle capture device to re-engage the needle 44 with the arm 42(not shown). The endoscope is then maneuvered to a different tissuelocation (e.g., at the posterior side of the stomach) and the process isrepeated at the next location. The suture process continues at alldesired locations (i.e., continuing to the anterior side of the stomach)for the particular length of suture.

Once the suturing at the respective locations for a particular suture iscomplete, the suture is then cinched and locked in the cinchedconfiguration with a cinch. In accord with one preferred cinch applyingsystem and method, described in co-owned US Pub. No. 2012/0158023, whichis hereby incorporated by reference herein in its entirety, a single-usesuture cinch system is provided which is advanceable through a workingchannel of the endoscope to apply a suture cinch to the suture adjacentthe inner stomach tissue to lock the suture relative to the tissue andretain the suture in the cinched configuration. In accord with anotherpreferred cinching system and method, described in co-owned U.S.Provisional App. No. 61/777,607, which is hereby incorporated byreference herein in its entirety, a reloadable cinch system can be usedto apply cinches to one or more strands of suture to retain the suturesin respective cinched configurations. All of the above can be usedendoscopically through a natural orifice, preferably under visualizationof an endoscope. The structure and operation of the preferred endoscopicsuturing system and cinch applying systems, as well as various alternateembodiments thereof, are described in greater detail in the referencedpublications. It is further appreciated that other endoscopic suturingsystems, and suture cinch applying systems, including other peripheralcomponents used in association therewith, can be used to effect themethod described herein, provided that they are suitable (for example,but not by way of limitation, in terms of safety and capability) for thetasks required.

The resulting stomach reduction procedure provides a seventy toseventy-five percent reduction in available stomach volume, greater thanany other incisionless procedure. Also, because it is incisionless, itis safer to patients and offers an easier recovery. Moreover, as anincisionless procedure, it is easier for the surgeon to effectivelyperform than other incisionless procedures, providing more direct accessto the fundus for reduction.

There have been described and illustrated herein several embodiments ofan incisionless endoluminal method of tissue approximation within thestomach to reduce the stomach volume. While particular embodiments ofthe invention have been described, it is not intended that the inventionbe limited thereto, as it is intended that the invention be as broad inscope as the art will allow and that the specification be read likewise.Thus, while particular systems, instruments, and devices have beendisclosed to position the sutures within the stomach tissue, and cinchand secure the sutures for tissue approximation, it will be appreciatedthat other system, instruments, and device can be used as well. Inaddition, while a particular preferred number of stitches has beendisclosed, it is appreciated that a fewer or more sutures can be used todraw the tissue into approximation, including a single suture extendingfrom near the pylorus to the upper end of the stomach, and that suchsuture can be cinched in stages. Also, while suturing in the describedpattern is a preferred method for effecting the described tissueapproximation of the anterior, posterior and lateral sides of thestomach in order to draw in the greater curvature, as well as therunning vertical approximation of the anterior and posterior sides afterthe greater curvature is drawn in, it is recognized that the method isnot limited to the use of suture, and that other tissue securingelements can be used. It will therefore be appreciated by those skilledin the art that yet other modifications could be made to the providedinvention without deviating from its spirit and scope as claimed.

What is claimed is:
 1. A method of treating obesity in a patient, thepatient having a stomach having an antrum, a central body, and a fundus,the stomach having a stomach wall with anterior, posterior, lateral andmedial sides, the method comprising: a) endoluminally passing a firsttissue securing element through the esophagus and into the stomach; b)from within the stomach, first attaching the first tissue securingelement through the anterior, posterior and lateral portions of thestomach wall at first locations; c) from within the stomach, firstapproximating the anterior, posterior and lateral portions of thestomach wall together with the first tissue securing element to reduce avolume of the stomach; and d) from within the stomach, first securingthe first tissue securing element relative to the stomach wall.
 2. Themethod of claim 1, wherein: said method is incisionless.
 3. The methodof claim 1, wherein: the first tissue securing element is at least onesuture.
 4. The method of claim 3, wherein: said first securing includesapplying a cinch to the first tissue securing element.
 5. The method ofclaim 1, wherein: said first attaching includes helically extending thefirst tissue securing element through the anterior, posterior andlateral portions at vertical displaced locations on the stomach wall,and said first approximating includes applying tension to the firsttissue securing element to draw the anterior, posterior and lateralportions together.
 6. The method of claim 1, further comprising: fromwithin the stomach, second attaching a second tissue securing elementthrough the anterior, posterior and lateral portions of the stomach wallat second locations vertically displaced from said first locations,wherein said second attaching is performed after said first attaching,said first approximating, and said first securing; from within thestomach, second approximating the anterior, posterior and lateralportions of the stomach wall together with the second tissue securingelement to reduce a volume of the stomach; and from within the stomach,second securing the second tissue securing element relative to thestomach wall.
 7. The method of claim 6, wherein: said first attaching,said first approximating, and said first locations are located below thefundus, and said second locations are located within said fundus.
 8. Themethod of claim 6, further comprising: after said second securing,approximating and securing the stomach wall together in theanterior-posterior direction from a lower end of the stomach to an upperend of the stomach.
 9. The method of claim 8, wherein: saidapproximating and securing the stomach wall together in theanterior-posterior direction includes placing a vertically displacedsuture pattern between the anterior and posterior sides of the stomachwall, cinching the suture, and then securing the suture to the stomachwall.
 10. The method of claim 6, wherein: said second securing includesapplying a cinch to the second tissue securing element.
 11. The methodof claim 1, further comprising: providing an endoscope having a proximalend, a distal end, and at least one working channel extending betweensaid proximal and distal ends, and a tissue suturing system coupled toadjacent the distal end, wherein the first tissue securing element ispassed through the at least one working channel to the tissue suturingsystem for said first attaching.
 12. The method of claim 11, wherein:said endoscope is a steerable endoscope, and said endoscope is steeredtoward said anterior, posterior and lateral portions of the stomachwall.
 13. The method of claim 1, wherein: in advance of said firstattaching, marking a guideline along at least one interior surface ofthe stomach wall.
 14. The method of claim 13, wherein: a guideline ismarked on each of the anterior and posterior interior surfaces of thestomach wall.
 15. The method of claim 13, wherein: the guideline ismarked with a laser coagulator.
 16. A method of treating obesity in apatient, the patient having a stomach having an antrum, a central body,and a fundus, the stomach having a stomach wall with anterior,posterior, lateral and medial sides, the method comprising: a)endoluminally first securing approximation of the anterior, posteriorand lateral sides of a stomach wall below the fundus; and then b)endoluminally second securing approximation of the anterior, posteriorand lateral sides of the stomach wall within the fundus.
 17. The methodof claim 16, wherein: said method is incisionless.
 18. The method ofclaim 16, further comprising: providing an endoscope having a proximalend, a distal end, and at least one working channel extending betweensaid proximal and distal ends, and a tissue suturing system coupled toadjacent the distal end, wherein said first securing includes using thetissue suturing system to suture a first suture through the anterior,posterior and lateral sides of the stomach wall below the fundus, andsaid second securing includes using the tissue suturing system to suturea second suture through the anterior, posterior and lateral sides of thestomach wall within the fundus.
 19. The method of claim 16, wherein:said first securing includes inserting suture through the stomach wall,and said second securing includes inserting suture through the stomachwall.
 20. The method of claim 19, wherein: first securing and saidsecond securing utilize different sutures.
 21. The method of claim 19,wherein: said first securing includes applying a cinch to the suture.22. The method of claim 16, wherein: said first securing draws thefundus downward toward the body of the stomach.
 23. The method of claim16, further comprising: b) after said second securing, endoluminallythird securing approximation of the anterior and posterior sides of thestomach at vertically displaced locations medial of said first andsecond securing.
 24. The method of claim 23, wherein: said thirdsecuring includes providing a running stitch between the anterior andposterior sides of the stomach from a lower end of the stomach to anupper end of the stomach.
 25. The method of claim 23, wherein: saidthird securing defines a passage from the upper end of the stomach tothe lower end of the stomach that exclude the secured approximation ofthe anterior, posterior, and lateral sides at the first and secondlocations.
 26. The method of claim 16, further comprising: in advance ofsaid first securing, marking a guideline along at least one interiorsurface of the stomach wall.
 27. The method of claim 26, wherein: aguideline is marked on each of the anterior and posterior interiorsurface of the stomach wall.
 28. The method of claim 26, wherein: theguideline is marked with a laser coagulator.
 29. A method of treatingobesity in a patient, the patient having a stomach having an antrum, acentral body, and a fundus, the stomach having a stomach wall withanterior, posterior, lateral and medial sides, the method comprising: a)providing an endoscopic tissue suturing system; b) endoluminally passingthe endoscopic tissue suturing system through a natural orifice into thestomach; c) using the endoscopic tissue suturing system to advance afirst suture through the anterior, posterior and lateral sides of thestomach wall at first locations below the fundus; d) cinching the firstsuture to draw inward into approximation the anterior, posterior andlateral sides at the first locations; e) using the endoscopic tissuesuturing system to advance a second suture through the anterior,posterior and lateral sides of the stomach wall at second locationsvertically displaced above the first locations, wherein the secondlocations are located within the fundus; and f) cinching the secondsuture to draw inward into approximation the anterior, posterior andlateral sides at the second locations.
 30. The method of claim 29,wherein: the first suture is advanced in a helical pattern about thestomach wall.
 31. The method of claim 30, wherein: the second suture isadvanced in a helical pattern about the stomach wall.
 32. The method ofclaim 29, wherein: said cinching the first suture includes applying afirst cinch to the first suture to secure the first suture in a cinchedconfiguration relative to the stomach wall, and said cinching the secondsuture includes applying a second cinch to the second suture to securethe second suture in a cinched configuration relative to the stomachwall.
 33. The method of claim 29, further comprising: using theendoscopic tissue suturing system to advance a third suture between theanterior and posterior sides of the stomach in an alternating pattern atvertical displaced locations; cinching said third suture to form apassage within the stomach that exclude the approximation of theanterior, posterior, and lateral sides at the first and secondlocations.
 34. The method of claim 29, further comprising: beforeadvancing the first suture through the anterior, posterior and lateralsides of the stomach wall, marking a guideline along the stomach wall.35. The method of claim 34, wherein: a separate guideline is marked oneach of the anterior and posterior sides of the interior stomach wall.36. The method of claim 34, wherein: the guideline is marked with alaser coagulator.
 37. A method of reshaping the stomach of a patient,the stomach having a stomach wall with anterior, posterior, lateral andmedial sides, the method comprising: a) endoscopically marking theanterior and posterior sides of the stomach along a greater curvature ofthe stomach to create guidelines; and b) endoscopically securing frominside the stomach the anterior and posterior sides of the stomachtogether at multiple locations to reduce a usable volume of the stomach.38. The method of claim 37, wherein: the endoscopically securingproceeds relative to the guidelines.
 39. The method of claim 37,wherein: the marking is made with a laser coagulator.
 40. The method ofclaim 37, wherein: the endoscopically securing also secures the lateralside of the stomach with the anterior and posterior sides.